Approach Considerations

The patient with orbital cellulitis should be promptly hospitalized for treatment, with hospitalization continuing until the patient is afebrile and has clearly improved clinically. Historically, the presence of subperiosteal or intraorbital abscess was an indication for surgical drainage in addition to antibiotic therapy. However, medical management alone can be successful in some patients without visual loss, especially those with small (<500 mm³), medially located, pediatric subperiosteal abscess.
[16, 17, 18]

Surgery

Canthotomy and cantholysis should be performed on an emergency basis if an orbital compartment syndrome is diagnosed at any point in the course of the disease. In patients with corneal exposure, continued lubrication is important.

Consider surgical drainage if the response to appropriate antibiotic therapy has been poor within 24-48 hours, if the CT scan shows the sinuses to be completely opacified, if the patient has an intraorbital abscess, or if there is a large subperiosteal abscess, especially in an adult. The drains should be left in place for several days. Repeat surgical drainage may be required. In cases of fungal infection, surgical debridement of the orbit is indicated and may require exenteration of the orbit and the sinuses.

Consultations

Ear, nose, and throat (ENT) consultation is required for cases of orbital cellulitis arising from sinus disease. Consult other specialists such as pediatricians, infectious disease specialists, and radiologists, as indicated. Neurosurgical consultation is indicated if brain abscesses appear.

Transfer

If necessary, the patient may be transferred for further diagnostic evaluation or for surgical intervention.

Deterrence/prevention

No foolproof method for the prevention of orbital cellulitis exists; however, proper treatment of conditions that may precipitate orbital cellulitis (eg, preseptal cellulitis, sinusitis, dental disease) is the best deterrent.

Diet

No special dietary requirements are indicated other than adequate hydration of the patient.

Follow-up

Patients are ideally monitored by an ophthalmologist, ENT specialist, and infectious disease specialist until symptoms, fever, WBC count, and imaging confirm that antibiotics can be discontinued.

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Inpatient Care

Closely monitor the patient at least daily, with vision reevaluated by standardized vision testing, preferably by the same examiner, as appropriate. The extent of erythema can be marked with a marking pen. Evaluate the antibiotic coverage daily and change it as needed, depending on the results of cultures and the patient's clinical course.
[19] Repeat CT scans if the patient's condition worsens or does not respond to appropriate antibiotics.

Once the patient is clearly improving and has been afebrile for at least 48 hours, he or she can be changed from IV antibiotics to oral antibiotics (eg, amoxicillin clavulanate, ampicillin, cefpodoxime, cefuroxime, cefprozil) for aerobic infections or to metronidazole for anaerobic infections.

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Pharmacologic Therapy

Medical care of orbital cellulitis consists of the proper use of the appropriate antibiotics. Broad-spectrum IV antibiotics should be started immediately and continued until the choice of antibiotics can be tailored for specifically identified pathogens identified on cultures. Typically, IV antibiotic therapy should be continued for 1-2 weeks and then followed by oral antibiotics for an additional 2-3 weeks. Fungal infection requires IV antifungal therapy along with surgical debridement.

Regarding pediatric care, a study by Emmett et al found that the length of IV therapy associated with successful nonsurgical management of children with subperiosteal abscess was considerably shorter than the length of time normally recommended in pediatric infectious disease literature. This result suggested that clinical judgment regarding each patient’s initial CT scan findings and evolving signs, symptoms, and laboratory profile should be taken into account when scheduling IV intervals.
[20]

Traditionally systemic steroids are not initiated until the patient improves with antibiotic or surgical intervention. One pediatric orbital cellulitis study suggests intravenous steroids with antibiotics upon hospital admission.
[21]

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Indications for Surgical Drainage

Surgical drainage of an orbital abscess is indicated in any of the following instances:

A decrease in vision occurs

An afferent pupillary defect develops

Proptosis progresses despite appropriate antibiotic therapy

The size of the abscess does not reduce on CT scan within 48-72 hours after appropriate antibiotics have been administered; if brain abscesses develop and do not respond to antibiotic therapy, craniotomy is indicated.

The presence of a drainable fluid collection is evident on CT scan in patients older than 16 years

A male patient with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited pain on eye movement, fever, headache, and malaise.

A male patient with orbital cellulitis who demonstrated proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited chemosis and resistance to retropulsion of the globe.